John Humphrey MD is a urology resident in the Department of Urology at Lahey Hospital and Medical Center, Burlington, MA. He graduated from Vanderbilt Medical School in 2009, and is expected to enter private practice after completion of residency in June 2015.

Introduction

Placement of an artificial urinary sphincter (AUS) has become the standard for treatment of severe male stress urinary incontinence (SUI). The device consists of three components: an inflatable cuff around the urethra, a reservoir, and a pump to transfer fluid from the cuff to the reservoir to open the urethra and urinate. It has been shown to positively affect patient quality of life as an effective treatment for post-prostatectomy incontinence (PPI)1-3.

Preoperative Assessment

Full history and physical should be obtained, as well as urinalysis and culture to assess for urinary tract infection. In post-prostatectomy patients, PSA should be obtained. HbA1C levels should be measured in diabetic patients to assess glucose control prior to the implantation of a synthetic device. Video urodynamics may be obtained to assess patients’ bladder compliance. Pre-operative cystoscopy is also performed to evaluate the lower urinary tract for any urethral or bladder pathology.

Surgical Technique

Preparation:

The patient is brought to the operating room where general anesthesia is administered. The patient receives standard perioperative intravenous antibiotic prophylaxis as well as subcutaneous heparin. Pneumatic boots are placed as well for prevention of venous thromboembolism. The patient is placed in the lithotomy position with care taken to pad all pressure points. The knees and hips are flexed at 90 degrees to protect against perineal nerve injury. The lower abdomen, genitalia, and perineum are shaving closely free of hair, then prepped and drapped in standard fashion. Care is taken to drape off the anus. A 12-french foley catheter is placed per urethra to gravity ensuring complete bladder emptying. The scrotum is retracted cephalad onto the anterior abdominal wall using three 2-0 silk sutures.

Incision and Dissection:

A midline 5-cm incision is marked over the perineal area with the base of the incision at the perineal body. The incision is carried down through Colles’ fascia to the bulbospongiosus muscle using bovie electrocautery. A Lone star retractor is then placed for retraction. Once the bulbospongiosus muscle is in view, it is incised in the midline, exposing the corpus spongiosum of the urethra. The muscle is then retracted using atraumatic hooks. A Babcock clamp is placed around the urethra to help facilitate its dissection from the corpora cavernosum. The ventral aspect of the urethra is sharply dissected off of the corpus cavernosum bilaterally. A space can then be palpated dorsal to the urethra on either side. A right angle clamp is then placed through this space and used to place a vessel loop posterior to the urethra to further facilitate dissection. The urethra is separated from the corpora cavernosa for a distance of 2cm using metzenbaum scissors. Once the urethra is mobilized, the measuring device is placed around the urethra to determine the correct cuff size to be used. The device should be placed snug, and a cuff ½ cm above the measured size is utilized (i.e., if the urethra is measured at a 4 cm snug, a 4.5 cm cuff is placed).

A separate 4 cm suprapubic incision is made 3 finger breadths above the pubic symphysis for placement of the reservoir and device connections. The incision is brought down through Scarpa’s fascia, and retractors are used to expose the rectus fascia. A 2cm horizontal incision is made in the rectus fascia, sparing the muscle underneath which is then split. A 2-0 prolene suture is placed at one end of the fascial incision for preparation of closure of the fascia after placement of the reservoir. Blunt dissection in the space of Retzius is utilized to create a pocket for the reservoir.

Device Preparation:

On the back table, the three sphincter components (pump, cuff, and reservoir) are prepared using normal saline. This involves removing any air pockets within the device that may cause malfunction. It is important to hold everything straight up so air goes up and out of the device. Two shodded snaps are used for each component once the air is removed. The cuff and pump are impregnated with inhibizone® coating designed to prevent infection. The pump itself is cycled with the tubing submerged under saline to prevent air in the system. All components are now prepared for implantation. A 35cc syringe is filled with 30cc of normal saline in preparation for filling of the reservoir.

Device Insertion:

The reservoir is first placed in the subfascial pocket in the space of Retzius. 23cc of normal saline is infused into the reservoir while it is posterior to the rectus fascia. The placement of the reservoir is ensured to not be under any tension after filling by confirming that the syringe does not back-fill with saline after filling the reservoir. The fluid is then removed from the reservoir in order to close the fascia and prevent injury to the device. The previously placed 2-0 prolene is used as a running suture to close the fascia. The reservoir is then again filled.

Attention is then turned towards the perineal incision for placement of the cuff. A right angle is placed dorsal to the urethra, and the cuff is brought around the urethra and secured. The tubing is placed through the “buckle.” The cuff is fastened by placing the strap over the button. The strap is then trimmed using curved Mayo scissors. The curved tubing passer is secured to the cuff tubing with 2 zero silk ties in preparation of passage of the tubing into the suprapubic incision from the perineal incision. The tubing is passed inside the bulbocavernosus muscle superficial to the pubic bone and rectus fascia, out through the suprapubic incision.

Skin of the suprapubic incision is grasped in order to create a subdartos pocket for the pump. Using metzenbaum scissors, a tunnel is created superficial to the rectus fascia into the scrotum in a dependent portion anterior to the testis. The pump is then placed in the subdartos pouch using ringed forceps.

Excess tubing from each of the components is trimmed. The reservoir is connected to the pump using a straight quick connect. Tubing is filled to the hub to prevent air bubbles, and the crimper is used to fasten the quick connect. The shods are then released. The pump is then connected to the cuff using a right angle quick connect in a similar fashion. The pump is cycled completely to ensure proper function of the device. The sphincter is then deactivated with a small amount of fluid left behind in the pump in order to allow for activation in 6 weeks.

Closure:

The bulbospongiosus muscle is cloed with a running 3-0 Vicryl suture. Subcutaneous tissue is closed in 2 layers with a 3-0 Vicryl. Skin is closed with a running 4-0 monocryl suture. The suprapubic incision is closed in a similar fashion.

Postoperative Care

The patient is admitted for overnight observation with Foley catheter drainage. Venous Thromboembolism prophylaxis in the form of subcutaneous heparin is continued while inpatient. The catheter is removed on postoperative day 1 and random post-void residuals are obtained to ensure bladder emptying. It is confirmed that the device is deactivated prior to discharge. The patient is then discharged home and scheduled for follow-up with the surgeon at 6 weeks for device activation. The patient should not perform any heavy lifting or strenuous activity in the immediate postoperative period.

Potential Complications4

Perineal pain

Dysuria – burning with urination

Migration of pump – Difficulty in palpating and using pump if not in dependent scrotum

Urethral atrophy – 7.9% of patients, causing recurrent incontinence

Infection (local wound) and Urethral Erosion – Occurs in ~8.5% of patients within 2 years

Mechanical Failure – Rates and timing of failure vary, but reimplantation remains an option in patients with good initial results